Provider Demographics
NPI:1871611814
Name:EXTENDED HOME CARE, INC
Entity type:Organization
Organization Name:EXTENDED HOME CARE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/SECRETARY OF THE BOARD
Authorized Official - Prefix:
Authorized Official - First Name:DEBRA
Authorized Official - Middle Name:M
Authorized Official - Last Name:CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:573-359-2473
Mailing Address - Street 1:105 RUSSELL ST
Mailing Address - Street 2:PO BOX 393
Mailing Address - City:HAYTI
Mailing Address - State:MO
Mailing Address - Zip Code:63851-1300
Mailing Address - Country:US
Mailing Address - Phone:573-359-2473
Mailing Address - Fax:573-359-1304
Practice Address - Street 1:105 RUSSELL ST
Practice Address - Street 2:
Practice Address - City:HAYTI
Practice Address - State:MO
Practice Address - Zip Code:63851-1300
Practice Address - Country:US
Practice Address - Phone:573-359-2473
Practice Address - Fax:573-359-1304
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-03-27
Last Update Date:2021-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO288892508Medicaid